E VE

V E RY C H ILD ’S
S ADVOCA
ADVO CA
CATTE

Women rarely hold office in Kenya. Florence Weke-sa is

an exception. As the only female member of the Kimilili
Municipal Council, she has become a voice for the mothers
of her ward and their children. Wrapped in her customary
bright colors, Florence stands out in a crowd — and so does
her message: “We need to care for our children.”

As a councilor, it is Florence’s duty to be present at every

funeral in her district. Too often, the funerals are direct
evidence of how quickly and how often diarrhea kills. The
funerals affect Florence as both a leader and a mother. She
vividly remembers a long week almost 20 years ago that she Florence attends a diarrheal disease control workshop held by PATH in Kenya.

spent nursing her son through a nearly fatal outbreak.

Last year, Florence took part in a pilot project run by PATH, joining a workshop that taught practical methods to reduce
diarrheal disease with a comprehensive approach: breastfeeding, use of oral rehydration solution, zinc treatment, and
proper hygiene. The workshop was part of a new, community-based approach to diarrheal disease control in the region
and a proving ground for techniques that will be integrated into Kenya’s National Diarrheal Disease Control policy. The
model will soon be transitioned to Vietnam as well.

Learning how to respond when diarrhea breaks out in a village — including slowing its spread from household to household,
keeping children hydrated, and ensuring the availability of clean water — gave her a fresh set of tools. Florence, who believes
a councilor’s job is to lead by example said, “The seminar opened up so much.”

Armed with information, Florence can provide immediate aid to families who come to her when a child is violently ill. She
travels every week to churches, schools, and health clinics, spreading awareness among parents and community leaders and
creating a safety net for her community’s children. According to Florence, “Diarrhea is still here — but it is no longer killing.”

27

The Chaudhary family from the village of Beli in the terai of Nepal stands
next to their new pit latrine.
We Have an Opportunity to Defeat
Diarrhea Now
Millions of children’s lives have been saved by
diarrheal disease interventions and millions more
can be saved moving forward.
Proven, lifesaving interventions already exist.
Unlike many other global health crises, cost-
effective, lifesaving prevention and treatment
methods already exist for diarrheal disease. These
interventions include ORS, ORT, optimal infant
and young child feeding practices, such as exclusive
breastfeeding, improved sanitation, and good
hygiene, as well as new tools like zinc treatment
and rotavirus vaccines. Because diarrheal disease
has many different causes and infections respond
differently to each intervention technique, a
coordinated approach is needed to address the
multiple sources of infection.
28
MD G 7 CA L L S FOR I MPROVED SA NI TATI ON B Y 2 0 1 5 . 2 4
Sanitation can be improved with:
ZComposting toilets
ZCoverable pit latrines
ZVentilated pit latrines
ZFlush/pour toilets that send waste to a piped sewer tank,
septic tank, or pit latrine
History has demonstrated that diarrheal disease
interventions work. Deaths of children under
the age of five have declined by nearly half since
the 1980s. But progress has stalled, and today 1.6
million children still die from diarrhea each year.
That’s too many.
We know what works. What we need now is the
political will and resources to make it happen.
World leaders are committed to child survival.
For a child in a poor country, simply surviving
early childhood can be at tremendous feat. For
example, one in six children in sub-Saharan
Africa die before their fifth birthday. A child in
Sierra Leone, which has the world’s highest child
mortality rate (262 out of 1,000 in 2007)56 is almost
100 times more likely to die than one born in
Sweden (with a rate of 3).57
COUN T R I E S WI T H T H E M O S T DEAT H S R ELATED TO D I A RRHEA L D I SEA SE
11 countries account for over 70% of global deaths each year from diarrheal disease
Deaths from Diarrhea
Countries
Source: Safe Water, Better Health (WHO, 2008).
Every year, 9.2 million children under the age of
five die, and 90 percent of those deaths are from
preventable conditions like diarrheal disease.23
To address the inequities between low-income
and wealthier countries, as well as the needs of
future generations everywhere, world leaders came
together in 2000 at the UN Millennium Summit
and drafted the MDGs — a “blue print for a better
future.”58 The goals establish a set of priorities to be
reached by 2015.
Aggressively combating diarrheal disease is crucial
to the success of two of the goals that came out
of the UN meeting. MDG 4 calls on the global
community to reduce the mortality rate of children
under the age of five by two-thirds or fewer than
five million deaths per year. MDG 7 calls for
reducing the number of people without access to
safe drinking water and sanitation by half.59
29
90% of deaths are children
As our world’s climate and demographics change
and natural resources are depleted, diarrheal
disease will become an even more significant
global health threat. The threat of diarrheal
disease outbreaks related to natural disasters
such as the cyclone in Myanmar portend major
diarrheal disease-related health crises in the future.
The International Federation of Red Cross and Red
Crescent Societies (IFRC) recently reported that
diarrheal disease such as cholera is increasingly
becoming the major cause of recurring disease
and death throughout the world, particularly in
sub-Saharan Africa. According to 2007 and 2008
IFRC data, approximately 60 percent of all requests
submitted for IFRC Disaster Response Emergency
funding were related to outbreaks of acute
diarrheal disease.60
 P O LI CY M AK ER & GLO BAL H EALT H FUND I NG RESEA RCH I ND I CATES:

Diarrheal disease ranks low among global health priorities

6% Diarrheal disease
7% Neonatal causes
7% Malnutrition
Percentage of Points Awarded

8% ARIs/Pneumonia
Measles
8%
Tuberculosis
(X out of 100)

14% Malaria
AIDS

18%

32%

Source: PATH.

“We have noticed a significant increase in the

number of operations undertaken to respond
to acute situations...This trend is the combined
result of poor hygiene practices, lack of
awareness of disease transmission, and a
shortage of safe water. Poor sanitation linked to
unplanned urbanization is also a major factor.
This is further complicated by the effects of
climate change, which have led to an increase in
the frequency and intensity of floods and related
epidemics...Humanitarian efforts have had some
impact, but data suggests we may be losing
the battle. This is especially true in countries Challenges Remain
affected by extreme poverty and conflict, where We have more proven intervention methods to
diarrheal diseases have become endemic. Such combat diarrheal disease than ever before, but the
countries now require long-term commitment if momentum to control it has slowed, and children
this worrying scenario is to be pushed back.” in the poorest countries are dying because they are
— Uli Jaspers, head of the IFRC water and sanitation team. 60 not getting the simple lifesaving treatments they
need to survive.

30
Three significant factors contribute to stalled or decreased attention and funding for diarrheal disease

Increased
Increased priority placed
placed on other diseases 14 3 2

D creased
Decr d public
bli awarenes
enesss off di
diarrhea
h as a
major
j childhood
hildh d killer
killer 3 8 4

Insufficient knowledge of diarrhea amongst

2 3 3
government officials
First
Second
A shift toward integrated management of 2 3
childhood illness Third

Lack of success in rolling out prevention and

3 2
treatment solutions

0 5 10 15 20
N =19 Number of Respondents
Source: PATH.

Today, although diarrhea is the second leading

killer of children under the age of five
worldwide, it is not treated as a global health
priority. In fact, a 2008 research study conducted
by PATH to evaluate the global health funding
and policy landscape found that diarrheal
disease ranked last among a list of other global
health issues. Public awareness of this issue is also
low, making it difficult to mobilize commitments
and resources. In donor countries such as the United
States, many are unaware of the burden of diarrheal
disease and the existing prevention and treatment
options.15
Z93 percent of Americans think child survival
should be a global health priority.
Z73 percent say knowing how to prevent the
major causes of child death is a major reason
Only 38 percent of children under five with
diarrhea receive oral rehydration
and continued feeding.
62 percent of infants under six months of
age are not exclusively breastfed.61
the US should be doing more to save lives around
the world.
ZHowever, most do not realize preventable and
treatable diarrheal disease is a leading killer.62
Despite the persistently high burden of the
disease, research into childhood diarrhea has
been steadily decreasing since the 1980s, according

31
P R OV EN INT ER V ENT IO NS FOR THE L EA D I NG KI L L ERS OF CHI L D REN

More proven interventions are available to prevent and treat diarrhea

us
than any other major child killer

s
er

si
an
a

liv

ep
xi

et
hy
ia

de

ls
lt
on

p
DS
a

ta

ta
m
es

as
he

ia
m

na

na
er
AI
sl

ar
r

eu

h
V/

et
ar

ea

eo

eo
rt
al
Pn

Pr
HI
Di

Bi
Preventive Interventions

N
*Breastfeeding 1 1 1

Insecticide-treated materials 1 1

Complementary feeding 1 1 1 1

Water, sanitation, hygiene 1

Hib vaccine 1

Zinc 1 1 2

Vitamin A 1 2 2

Antenatal steroids 1

Newborn temperature 2
management
Tetanus toxoid 1

Nevirapine and replacment 1

feeding
Antibiotics for premature 2 2
rupture of memberanes
Clean delivery 1 1

Measles vaccine 1

Antimalarial intermittent 1
preventive treatment in
pregnancy

Treatment Interventions
Oral rehydration therapy 1

Antibiotics for pneumonia 1

Antimalarials 1

Antibiotics for sepsis 1

Newborn resucitation 2

Antibiotics for dysentery 1

Zinc 1

Vitamin A 1

1 Level 1 (sufficient) evidence Hib=Haemophilus influenza type b

2 Level 2 (limited) evidence * Exclusive breastfeeding in

the first 6 months of life and
continued breastfeeding from
SOURCE: Jones G Bryce J. et al., Lancet CS, series 2003. 6 to 11 months.

32
ONLY 4 . 4 P E R C EN
E N T O F G LO
O BA L H EA LT H F UN
U N D IN
I N G G O ES TO
D IA R R HE A L D I S E AS E R ES EAR C H & DEV ELO
E LO
LOPME
PME N T
to the WHO. Funds available for research into
diarrhea are less than those available for
research into other diseases that cause fewer
deaths. For example, diarrheal disease receives
less than one-tenth the funding that Type 2
diabetes receives.63, 64
Barriers exist at both the country level, with lack of
awareness of and access to life-saving interventions,
and at the global level, with advocacy challenges that
33
T O WA RD
100%
% OF
GLOBAL
HEALTH
SPENDING
4.4%
0%
Source: George Institute, 2008.
have prevented the global health community from
mobilizing around the issue and committing to stop
it. Additionally, research also indicates that while a
great deal is known about effective treatments for
diarrhea, there is a critical lack of knowledge on
how to make sure the children who need diarrheal
disease treatment can get access to it.63
Widespread adoption of proven, existing water,
sanitation, hygiene, and health interventions has
 INCREASING ACCESS TO INTERVENTIONS

Interventions seen as an integral part of a coordinated approach to fighting diarrheal disease:

Clean water and sanitation 93%

ORS/ORT 93%

Breastfeeding 83%

Vaccines 80%

Zinc 63%

Nutrition 63%

Restorative feeding 33%

N = 30
Diagnostics 23%

Anti-diarrheals 20%

0 20 40 60 80 100

Increasing access to proven interventions is believed to be the most

effective way to accelerate progress toward MDG 4

SOURCE: PATH.

been hampered by the lack of political leadership and
commitment to fight diarrheal disease. In turn, this
has led to a decline in funding and research on the
issue. Interventions that may be easily accessible in
the developed world are not as accessible to the
children who need them most in the developing world.
The challenges are great but so are the
opportunities to save millions of children’s lives
worldwide. Leaders from all sectors can take
practical steps to begin to galvanize the funding
and political will necessary to reduce the illness
and deaths from diarrhea. These steps include:
Z Investing the resources to ensure that funding for
diarrheal disease, including both prevention and
treatment interventions, is commensurate with the
scope of the burden the illness places on families
and communities around the world.
Z Redoubling commitment to reducing the child
mortality MDG by 2015 as stated in the WHO/

34
]The persisting high mortality rate from diarrhea in the presence of
existing, cost-effective interventions and available resources to implement
them represents a continuing scandal. ^ — Olivier Fontaine, Margaret Kosek, Shinjini Bhatnagar, Cynthia
Boschi-Pinto et al. PLOS Medicine.63

sanitation, water and hygiene; further including

sanitation, water, and hygiene interventions in health
efforts to prevent and control diarrheal disease.

By reprioritizing diarrheal disease as a global

health priority and educating, increasing awareness
among, and mobilizing the global community
around the burden of diarrheal disease and the
lifesaving health, hygiene, sanitation, and safe water
interventions that exist today, we can save lives. A
coordinated approach will be crucial to the effort
to ensure that this preventable and treatable disease
is no longer a leading killer of children. Because no
child should die from diarrhea.

UNICEF joint statement on the MDGs, focusing

on addressing diarrheal disease as a strategy for
clear and rapid progress towards that goal.

Z Investing in the research and development of new

effective, appropriate, and affordable prevention
and treatment options for diarrheal disease.

Z Prioritizing the implementation of an appropriate

combination of interventions against diarrhea,
including improved water, hygiene, and sanitation;
optimal infant and young child feeding; increased
access to and uptake of vitamin A, ORS, and zinc;
and rotavirus vaccination.

Z Including diarrhea prevention and control in

international, regional, and country plans on

35
End Notes
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WEBSITES
Controlling Diarrheal Disease:
http://www.path.org/diarrheal-disease.php.
Enhanced Diarrheal Disease Control Resource Center:
http://www.eddcontrol.org.
PATH: http://www.path.org.
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Shigellosis and Enterotoxigenic Escherichia Coli (ETEC):
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http://www.path.org/files/IMM_EDDrotavaccines_fs.pdf.
Zinc Treatment for Diarrhea:
http://www.path.org/files/IMM_EDD-zinc_fs.pdf.
Photography Credits
FRONT COVER 1. Philippe Blanc (left, top), 2. Amy Gottlieb (left,
bottom), 3. Amy Gottlieb (middle), 4. PATH/Satvir Malholtra (right,
top), 5. Amy Gottlieb (right, bottom)
BACKGROUND Page 6. PATH/Janie Hayes, Page 7. PATH
PREVENTION Page 11. Amy Gottlieb, Page 12. WaterAid/Marco Betti
(all), Page 13. Amy Gottlieb (all), Page 14. Amy Gottlieb (all), Page
15. Amy Gottlieb (all), Page 16. Richard Franco (top), Richard Lord
(bottom), Page 18. PATH/Mike Wang
TREATMENT Page 22. Amy Gottlieb (all), Page 23. PATH, Page 24.
PATH/Satvir Malholtra

UN Millenium Project: www.unmillenniumproject.org/goals/index. LOOKING FORWARD Page 27. PATH/Janie Hayes, Page 28.
WaterAid/Marco Betti, Page 30. PATH/Mike Wang, Page 33. Heng
WaterAid America: http://www.wateraidamerica.org. Chivoan, Page 35. Amy Gottlieb

WaterAid: http://www.wateraid.org/uk. BACK COVER Amy Gottlieb (left), Amy Gottlieb (middle), David and
Lucile Packard Foundation(right)
World Health Organization: www.who.int/.

FACT SHEETS
Accelerating the Development of New Rotavirus Vaccines:
http://www.path.org/files/VAC_rotavirus_fs.pdf.

Advancing New Rotavirus Vaccines:

http://www.path.org/files/VAC_rotavirus_fs.pdf.

An Integrated Approach to Confronting Diarrheal Disease:

http://www.path.org/files/VAC_dd_approach_fs.pdf.

Breastfeeding and Diarrhea:

http://www.path.org/files/IMM_EDD-breastfeeding_fs.pdf.

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For more information on diarrheal disease please visit
www.eddcontrol.org and www.path.org.

This report was developed with generous support from the GAVI Alliance and the Bill & Melinda Gates Foundation.

PATH is an international, nonprofit organization that creates sustainable, culturally

1800 K Street NW, Suite 800
Washington, DC 20006 USA
info@path.org www.path.org
relevant solutions, enabling communities worldwide to break longstanding cycles of
poor health. By collaborating with diverse public- and private-sector partners, PATH
helps provide appropriate health technologies and vital strategies that change the
way people think and act. PATH’s work improves global health and well-being.

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